Can the patient with a history of insomnia and Attention Deficit Hyperactivity Disorder (ADHD) be restarted on Ambien (zolpidem) and Trazodone (trazodone) for sleep management following an appendectomy for appendicitis?

From the Guidelines

You should not restart the patient's trazodone for insomnia while they are hospitalized for appendicitis awaiting appendectomy, as the American Academy of Sleep Medicine suggests not using trazodone as a treatment for sleep onset or sleep maintenance insomnia in adults, according to the clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults 1. However, you can consider restarting the patient's Ambien (zolpidem) for insomnia, since the American Academy of Sleep Medicine suggests using zolpidem as a treatment for sleep onset and sleep maintenance insomnia in adults 1. Since you've completed the medication reconciliation and these medications are for the patient's pre-existing insomnia condition, continuing Ambien is appropriate to maintain sleep hygiene, especially in the hospital setting where sleep disruption is common. Abrupt discontinuation of sleep medications can lead to rebound insomnia and potentially worsen the patient's comfort during hospitalization. However, be mindful that Ambien may cause confusion or sedation that could complicate post-surgical recovery, so consider timing the dose appropriately (at bedtime) and potentially using a lower dose initially in the hospital setting. Also, ensure there are no new contraindications or medication interactions with any perioperative medications that will be administered. Document the restart orders clearly, including the specific doses the patient was taking at home, and reassess the need for these medications daily during the hospital stay. It's also important to note that cognitive behavioral therapy for insomnia (CBT-I) is an effective therapy for chronic insomnia disorder and can be performed and prescribed in the primary care setting, as recommended by the American College of Physicians 1.

From the FDA Drug Label

5.2 CNS-Depressant Effects and Next-Day Impairment Zolpidem tartrate, like other sedative-hypnotic drugs, has CNS-depressant effects. Coadministration with other CNS depressants (e.g., benzodiazepines, opioids, tricyclic antidepressants, alcohol) increases the risk of CNS depression [see DRUG INTERACTIONS (7. 1)]. Dosage adjustments of zolpidem tartrate and of other concomitant CNS depressants may be necessary when zolpidem tartrate is administered with such agents because of the potentially additive effects.

The patient is taking Ambien (zolpidem) and Trazodone for sleep, and also has a history of ADHD and insomnia. Considering the patient is scheduled for an appendectomy, it is crucial to weigh the risks and benefits of restarting these medications.

• The use of zolpidem with other CNS depressants, such as trazodone, may increase the risk of CNS depression.
• There is a risk of next-day psychomotor impairment, including impaired driving, if zolpidem is taken with less than a full night of sleep remaining.
• Patients should be warned against driving and other activities requiring complete mental alertness if zolpidem is taken in these circumstances. Given the potential risks, it is recommended to exercise caution when deciding to restart the patient on these medications, especially in the context of an upcoming surgery and potential post-operative needs 2, 2.

From the Research

Medication Considerations for Appendicitis Patient

• The patient is scheduled for an appendectomy and has a history of insomnia and ADHD, for which they take Ambien and trazodone for sleep.
• According to 3, trazodone is an antidepressant with a favorable profile for treating depression, including symptoms like insomnia, and is usually well-tolerated with a low risk of side effects.
• However, the use of sedating medications like trazodone and Ambien in the perioperative period should be carefully considered due to the potential for respiratory depression, especially in patients with sleep-disordered breathing 4.
• A study on hypnotic use for insomnia management in chronic obstructive pulmonary disease found that sedating antidepressants like trazodone can be effective for treating insomnia, but the safety and efficacy of these medications in patients with respiratory conditions should be carefully evaluated 5.

Appendectomy and Perioperative Care

• The patient is scheduled for an appendectomy, and the optimal timing of the surgery is important to consider.
• A study on the optimal time to appendectomy found that delaying surgery beyond 12 hours from admission can result in longer lengths of stay and higher 30-day readmission risk 6.
• The study also identified certain patient subgroups, such as older patients and those with American Society of Anesthesiologist score II to III, who may be less tolerant of surgical delays and require earlier intervention 6.
• Another study compared appendectomy versus antibiotic treatment for acute appendicitis and found that antibiotics may be associated with higher rates of unsuccessful treatment, but may also reduce wound infections 7.